Questions 9

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Transcultural Concepts in Nursing Care Answers Test Banks Questions

Question 1 of 5

After assessing a patient in the emergency department, the nurse determines that the patient has a form of arthritis that is a medical emergency. For which type of arthritis should the nurse plan care for this patient?

Correct Answer: B

Rationale: Septic arthritis is a form of arthritis that is considered a medical emergency. It is an acute, severe infection of a joint often caused by bacteria entering the joint space. Prompt recognition and treatment are essential to prevent irreversible joint damage and systemic spread of the infection. Symptoms of septic arthritis typically include severe joint pain, swelling, redness, warmth, and decreased range of motion. The nurse should plan care to facilitate rapid diagnosis, administration of antibiotics, joint drainage if necessary, and close monitoring for complications. Osteoarthritis, gouty arthritis, and reactive arthritis are not medical emergencies and generally require different treatment approaches.

Question 2 of 5

The nurse is preparing to assess a patient’s musculoskeletal system. What should the nurse keep in mind as being the most common manifestations of musculoskeletal disorders?

Correct Answer: A

Rationale: Pain and limited mobility are the most common manifestations of musculoskeletal disorders. Patients with musculoskeletal issues often experience pain, which can be localized to the affected area or radiate to other parts of the body. Pain can range from mild discomfort to severe and debilitating. Limited mobility refers to a decreased range of motion in joints or difficulty moving due to stiffness, weakness, or structural abnormalities. These symptoms can significantly impact a patient's daily activities and quality of life. Pallor, cyanosis, decreased pulses, and exaggerated reflexes are not typically associated with musculoskeletal disorders and may indicate other health conditions.

Question 3 of 5

The three pathological factors that are associated with the formation of a thrombus are known as what?

Correct Answer: D

Rationale: Virchow's triad describes the three pathological factors that are associated with the formation of a thrombus. These factors include endothelial injury, abnormal blood flow, and hypercoagulability. Endothelial injury disrupts the normal function of the endothelium, leading to the exposure of collagen and tissue factor, which triggers the coagulation cascade. Abnormal blood flow can result in stasis or turbulence, which promotes the accumulation of platelets and clotting factors. Hypercoagulability refers to an increase in the tendency of the blood to clot, which can be caused by various conditions such as genetic disorders, cancer, and certain medications. These three factors work together to increase the risk of thrombus formation.

Question 4 of 5

The nurse is caring for a patient in the spinal shock phase following a spinal cord injury. Which action is the most appropriate to maintain this patient’s bladder functioning?

Correct Answer: B

Rationale: In the spinal shock phase following a spinal cord injury, the patient may have impaired bladder functioning due to the disruption of nerve pathways. Stimulating voiding using Crede's method (choice A) is not appropriate as it can increase the risk of causing further harm to the patient's bladder. Catheterizing with a straight catheter every 3 to 4 hours (choice C) is also not recommended unless there is a specific indication for catheterization. Inserting an indwelling urinary catheter to accurately measure output (choice D) is invasive and may increase the risk of infection.

Question 5 of 5

During an assessment, a client with left-sided congestive heart failure (CHF) and severe shortness of breath tells the nurse about not having enough money to purchase medications. What nursing diagnosis is of the greatest initial importance when planning care?

Correct Answer: B

Rationale: In this situation, the nursing diagnosis of Ineffective Health Management is of the greatest initial importance when planning care. The client's inability to afford medications due to financial constraints directly affects their ability to manage their health effectively. Lack of funds may lead to non-adherence to the prescribed treatment plan, which can worsen the client's condition. By addressing the financial barriers to medication access, the nurse can help the client improve their health management and outcomes. This nursing diagnosis is a priority as it addresses the immediate need to ensure the client's access to necessary medications and prevent exacerbation of their congestive heart failure.

Similar Questions

During an assessment, a client with left-sided congestive heart failure (CHF) and severe shortness of breath tells the nurse about not having enough money to purchase medications. What nursing diagnosis is of the greatest initial importance when planning care?
The nurse is caring for a patient with a small-bowel obstruction. Which action is the highest priority for this patient?
The nurse is concerned that a client with an alteration in perfusion is at risk for inadequate oxygenation. What should the nurse consider when planning for this client's potential health problem?
A nurse is caring for a client with cardiomyopathy who is experiencing activity intolerance. Which intervention is inappropriate for this nursing diagnosis?
The nurse is providing teaching about infusion of albumin 5% to a client recovering from hypovolemic shock. Which statement by the client indicates that teaching was effective?

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